Could Controlled Imaging Rein in Suboptimal Use of MRI, CT and Ultrasound Exams?

I have mentioned that I use distance running for most of my aerobic exercise. One of the fringe benefits is that I get most of my good “outside the box” ideas while footing away the miles.

Part of it is that there’s not a whole lot to occupy my mind while I’m out there for an hour-plus at a time. I’m not reading anything, holding conversations, or being interrupted by ringing phones and cellphone apps. I have heard the phrase “moving meditation” as an apt description for how my mind can wander while I chug along.

Once, I fancied that the act of steady physical exertion generally got my juices flowing and contributed to the process. Perhaps that is true, but I have come to believe that another factor is at work. I suspect that resources are partially diverted from my brain to keep me moving at pace, and some higher-order functions preventing innovation might be damped down in the process.

In other words: I have the same number of ideas I usually do, but the self-critical part of my brain is less able or willing to pipe up and say, “That is a really dumb idea. It wouldn’t work because [reasons].” By the time I am staggering back into my house, I can be convinced I had a couple of great breakthroughs.

Even when I have recovered enough for critical self-reflection, notions that got past my internal gatekeeper can still seem like great ones. (Sometimes they are. The gatekeeper isn’t infallible and, left to its own devices, it surely squelches viable stuff all the time.)

Accordingly, when I recently found myself hoofing up one of my more onerous hills, I thought of something that could conceivably entice me to leave my teleradiology life behind and one day return to working on site. This was something that wasn’t just good for me, but for our field as a whole.

I wouldn’t have been doing telerad for the past 11.5 years if I didn’t like it, and I don’t expect that to change. However, there’s a certain commonality to most telerad work: We tend not to have much control over anything.

Your mileage may vary, but in the time I have been working remotely, I could probably count on my fingers the number of times I have been able to protocol an imaging study. We can groan about how the wrong MRI sequences got done, how there should have been a pre-contrast phase to a CT, why the sono tech didn’t bother to use Doppler, or even that the entirely wrong modality was used for the clinical scenario. However, it’s too late to do anything about it now, and we tend not to have the clout to prevent the same thing from happening an infinite number of times in the future.

Most of the dissatisfactions I have had and heard from other rads (on site as well as those working remotely) relate, ultimately, to a lack of control. Our field might very well be called Uncontrolled Imaging, and that goes far beyond protocoling studies. If we had control, for instance, we might be able to force referrers to provide relevant clinical histories. We might avert needless excess imaging, for instance, by pointing out that a prospective stone CT patient has already undergone 12 such scans in the last couple of months, and maybe it’s time for ultrasound. Alternately, we might review previous cases to show that a would-be “f/u nodule” lung scan today maybe shouldn’t happen, since the patient last had a chest CT three years ago with the scan showing that all lesions were tiny and had been stable for a decade.

We often don’t even have control over our own reports but I won’t get into the weeds about places insisting on clunky templates, or non-physician regulators demanding specific verbiage lest we get into trouble for non-compliance (I’ve written about that before). Instead, let me move on to share my notion of Controlled Imaging, an antidote to the Uncontrolled version many of us endure.

In my probably aerobically-addled vision the other day, I imagined an ER-adjacent imaging suite. A referrer would come into the central room to be greeted by the on-duty Controlling rad. The referring clinician would present his or her request for imaging: “My patient has issues X, Y, and Z. I was thinking of a CT for him.” Perhaps the referring clinician would ask “What type of study would be best?”

The rad would have his RIS/PACS station ready to check the patient’s background and review recent studies. He or she might say, “Looks like your patient has had three visits to this ER for X, Y, and Z during the past year, and here’s what imaging has already turned up.” Another response may be along the lines of … “I get that you want to avoid contrast because the patient says there’s an allergy, but we premedicated her for a scan two months ago and contrast was nicely tolerated.” Another response might be: “If you’re thinking about DVT, maybe we should start with ultrasound rather than a CT venogram.”

I have no idea whether the department would be able to bill for a “radiology consultation” visit for such sessions, but that might be worth exploring.

The rad’s room would have doors leading to imaging areas for each of the major modalities so the rad could visit (and be visited by) techs as needed. Some of the best MRI body cases we did back in my fellowship had an attending rad right there with the tech with the ability to review images as they were obtained, and repeat sequences or modify protocols on the fly. One rad liked to go into the rooms to personally keep demented patients on-task re: staying still, not breathing, etc.

Such a “hands-on” approach would enable us to guide patients through the imaging process. If CT turned up something meriting sono for further characterization, a rad could immediately make that happen rather than rendering a report and hoping the referrer noticed/agreed with him or her perhaps getting around to ordering the sono hours later.

There may be one minor speed bump. “Controlled Imaging” sounds throttled or held back. We would want a snazzier, more marketable moniker. Maybe “Optimized Imaging” would work? After all, we would be severely cutting back on the frequency of “suboptimal” studies.